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A key factor in empowering healthcare professionals to impact patient care is the ready access to centralized patient data, however, at many facilities a significant barrier to retrieving this information exists. Vital medical information is often fragmented, with data distributed across various databases and systems, managed by software programs operating in different languages and platforms. This fragmentation may negatively impact patient safety and, ultimately, hospital finances, since the federal government will no longer pay for additional care associated with some hospital-acquired conditions.1

Clinical decision support software (CDSS) leverages clinical information to improve the quality and safety of care by combining patient information from many sources within the institutions and making it immediately available. A 2009 study found that hospitals with automated notes and records, order entry, and CDSS had fewer complications, lower mortality rates, and lower costs. Higher scores in decision support were associated with a 16% decrease in complications, as well as $538 lower costs for all hospital admissions.2

The cornerstone of CDSS technology is its ability to interface with multiple hospital information sources, including laboratory, microbiology, pathology, pharmacy, admission/discharge/transfer, patient demographics and vital signs, radiology, and surgery. This technology offers a range of validated clinical tools, reports, and alerts that provide active, real-time electronic surveillance to increase adherence to clinical guidelines and reporting requirements. It also enhances efficiency and helps improve patient care and safety throughout a healthcare organization. CDSS also saves money for hospitals and helps prevent medical errors.3,4

Case study/background

The Baptist Memorial Health Care Corporation is headquartered in Memphis and includes 14 acute care hospitals located in 3 states. Baptist Memorial Hospital Memphis (Baptist) is a 728-bed tertiary, referral hospital. The health system is currently transitioning to computerized prescriber order entry (CPOE) and upgrading all automated dispensing devices system-wide. Baptist began searching for CDSS primarily to support its infection prevention (IP) efforts to increase timely identification/intervention and in response to predictions of increased regulatory reporting.5

Considerations for the CDSS purchase centered on the program's ability to integrate with multiple clinical systems across the hospitals; integrate with the National Healthcare Safety Network (NHSN); comply with Centers for Medicare and Medicaid Services core measures and demonstrate compliance; and provide reports, alerts, and customization to fit each setting. Real-time data availability was significant, since the current program at Baptist had a 12-hour delay. As the multidisciplinary team at Baptist began to research existing infection prevention software, it became apparent that including the pharmacy components would significantly improve the IP antibiotic stewardship efforts already begun system-wide.

The business model presented to senior management summarized an anticipated return on investment for both IP and pharmacy. Choosing a CDSS vendor was based on the ability to meet items of importance on a check list, input from current system users, company reputation, professional product reviews, and the voice of the end users.

Implementation

Initially the technology was installed for the IP team, however, as the search progressed, it was determined that the pharmacy components in the CDSS program chosen would increase pharmacy effectiveness, as well. The implementation team worked closely with the hospital's clinical and information technology teams to plan and execute the implementation while addressing any challenges that arose. Key clinical staff members from the hospital were involved in the process to ensure that the technology was optimized to meet the needs of clinical users.

The new software was implemented in late 2011. With the transition from the previous system utilized for surveillance to the new integrated system, the IP program soon began to expand beyond expectations. Utilizing CDSS each morning, the IP nurses can review alerts, identify patients who may need transmission-based precautions, and interact with the patient's caregivers to expedite the precautions. Customized views make it possible to quickly see important microbiology results for all units in the facility, which streamlines identification of follow-up needs and allows for efficient preparation of patient-specific worklists before rounding.

One of the most helpful features of the new system is a program that facilitates hospital-wide infection surveillance, prevention, control, and reporting in a user-friendly workflow tool. These worksheets follow the NHSN requirements for each infection type to document findings, note comments for future reviewers, and upload the infection information in a formatted NHSN report. Reporting mechanisms format this information into visual displays readily available for education to hospital staff and management.

Performing surveillance through these interactive tools improves the ability of the IP nurse to recognize patient condition changes, adverse events, and other threats to patient safety more quickly. Decision making is streamlined by filtering and congregating important information needed to make clinical recommendations and/or changes in therapy. The information can be formatted so that data can be queried and specific results retrieved in a format that's useful for the IP team.

In the Baptist health system, users have become creative with the program's IP aspects. ED staff, pharmacy, and rounding teams use the programs for real-time access to medication, lab, and microbiology results. For example, the IP staff identifies and flags positive cultures of patients discharged early from the ED; the pharmacists follow up with all positive cultures and sensitivities, present findings, and make recommendations to the ED physicians; these physicians then call in prescriptions for the infections. Other areas, such as outpatient services, use the system to identify returning patients who may be colonized with resistant organisms.

Increasing pharmacist participation on patient care teams, the avoidance of errors, and improvement in health outcomes are important components of the Pharmacy Practice Model Initiative (PPMI). In anticipation of CPOE and following the recommendations of the PPMI, the pharmacy management team at Baptist redistributed 30 centralized pharmacists into 10 patient care areas within the institution, creating a new role of decentralized pharmacists.

The CDSS previously implemented primarily for IP was expanded to support pharmacy interventions. Specifically, CDSS was customized to include interventions specific to the Baptist Memphis facility, and soft dollar cost-savings and time spent were associated with each intervention. In January 2013, staff completed a training program on documenting actions and interventions, in addition to daily responsibilities such as order entry, verification, and dispensing. Computerized documentation began on February 1, 2013.

After the decentralized pharmacists became familiar with documenting interventions, alerts were developed to be executed daily. Alerts highlight clinical situations that need to be identified, assessed, and addressed. The first 10 alerts chosen were specific clinical situations where the intervention was predetermined and the physician communication notes had already been developed and approved. With CDSS, the decentralized pharmacist can address alerts before rounding and review them if necessary as talking points during rounds. These alerts save decentralized pharmacists, valuable hours, since they only have limited time dedicated to chart reviews. Decentralized pharmacists can develop custom alerts quickly and easily. For example, an alert was created to identify when a patient was ordered duplicate anticoagulants. Discontinuing the unnecessary medication may prevent a major bleeding event.

The pharmacy department uses the software in many different ways to automatically compile, format, and display patient information from various sources and show custom views for each task at hand. The software facilitates clinical workflow, interventions, and documentation. This clinical productivity and workflow management tool provides measurement reports for patient safety, workload, productivity, and cost savings. Decentralized pharmacists are able to communicate to each other and account for actions and interventions completed beyond their duties of order entry and verification. The ability for the user to customize alerts and have them delivered by e-mail, pager, or smart phone helps improve patient and medication safety.

Pharmacists employ proactive monitoring using pre-built clinical alerts that provide instant access to critical patient information, such as changes in status and trends in the patient's care. For example, alerts are used to identify patients with critical lab values indicating hypokalemia, hypophosphatemia, or hypomagnesemia, allowing pharmacy to send an as-needed electrolyte dose up to the floor in anticipation of the order.

After data capture, a multi-disciplinary analysis committee reviews the adverse drug events (ADEs). Primarily, the committee focuses on the ADEs and interventions to improve patient safety by preventing further occurrences. This category of interventions accounts for the largest dollar amount of cost savings. A significant benefit of CDSS is that reports are dynamic and can be updated as information changes, creating an opportunity to validate the intervention data and to ensure there's a control mechanism in place to accurately reflect cost savings.

Results

CDSS implementation has improved the workflow of IP nurses. For example, these nurses now have time to participate in multi-disciplinary rounding on the units, which has resulted in improved communication with clinical nurses and has expedited recommendations for interventions such as transmission-based precautions.

The efficiency gained in standardizing workflow among all IP nurses has allowed for expansion of the infection control plan. Initiatives include prevalence studies of central lines and urinary catheters. This baseline will be used in the future as the mark for continued improvement and include areas not covered previously.

After the education and implementation of CDSS in the pharmacy, the department was able to justify decentralization of staff pharmacists both fiscally and through its impact on patient outcomes. Between February and July 2013 after implementing CDSS, potential soft-dollar cost-savings were estimated at $500,000. The majority of the interventions were prevention of ADEs.

The future

The opportunity exists for additional education and improved CDSS utilization. This is being accomplished through online training, webinars, and live training sessions provided by an internal super-user. This additional education and improved use of CDSS will enable better reporting of results and improvements to the patients, families, nurses, and physicians. Next steps include expanded access and use of the system to include managers and physicians.

CDSS successfully addresses critical patient safety problems in healthcare today, including hospital-acquired infections and drug-resistant infectious diseases, by utilizing alerts that will tell the pharmacist, for example, when there's a "drug and bug" mismatch. In the foreseeable future, the pharmacy management team hopes to utilize the decentralized pharmacists to assist with antimicrobial stewardship through CDSS. In the ED, pharmacists have developed their own intervention categories and are expected to use CDSS to justify their presence by accurately capturing their actions and interventions. Potentially, CDSS may offer clinical business intelligence tools that could provide healthcare leaders with a clearer understanding of concerns related to patient safety, quality, and costs by organizing and presenting important clinical, business, and operations data for decision-making and resource-allocation purposes.